No Gold Standard for Diagnosis or Treatment of Patellofemoral Pain Syndrome

Physical therapists often treat athletes with patellofemoral pain syndrome (PFPS), a common cause of knee pain when squatting, kneeling, running, and going up and down stairs. There isn’t one individual test that can confirm the diagnosis of PFPS. And there isn’t one best way to treat the problem either.

That puts therapists in a bit of a quandary when it comes to choosing the right way to treat patients with this problem. Many studies have been done to sort out what works best. Is it taping? Taping with exercise? Exercise alone? What kind of exercise is advised?

It is believed that PFPS occurs because of altered biomechanics between the patella (knee cap) and the femur (thigh bone). The patellofemoral joint is where the kneecap moves up and down over the lower end of the femur. It makes sense that restoring normal patellofemoral biomechanics should reduce pain and improve function. But a one-size-fits-all type of treatment program has not been found.

Studies show that taping the knee to improve patellar tracking (movement up and down over the femur) can be helpful. But the proper (most effective) method of taping is still under investigation. Other studies have shown that strengthening the quadriceps muscle over the front of the thigh and/or hip muscles can alter the symptoms of PFPS. Exercising these muscles seems to improve proprioception (sense of joint position) in the leg. The result is decreased pain and improved function.

Yet another direction in treatment has been the use of manual therapy techniques for PFPS. In this approach, the therapist uses nonthrust or thrust manipulations of the hip, knee, and/or patella to relieve pain and improve movement. There is support that this method is successful.

In this study, five patients with PFPS were treated with a multimodal approach. This means more than one treatment method was used. Manual therapy, patellar taping, exercise, and orthotics (shoe inserts) were used to treat the entire lower extremity rather than just addressing the patellofemoral joint alone. This approach is referred to as a regional interdependent management of the lower quarter to manage patellofemoral pain.

The five patients all had been diagnosed with PFPS. They were between the ages of 14 and 50 years old. Everyone completed a battery of tests before and after treatment. The Numeric Pain Rating Scale and Kujala Anterior Knee Pain Scale (AKPS) were used to measure pain intensity. The Lower Extremity Functional Scale (LEFS) was used to measure level of difficulty with tasks and function. And the Global Rating of Change Scale (GRPS) was used to measure patient perception of change from beginning to end.

A physical therapist performed an in-depth exam of each subject. Posture, neurologic screening (including neurodynamic testing), and muscle flexibility were all evaluated carefully. Hip and knee motion and strength were also assessed. Each of the five patients was described along with the results of their tests.

The authors provided a table summarizing the exercises and manual therapy techniques used. Non-weight bearing exercises, weight-bearing exercises, and stretches were prescribed. Photos and description of the nonthrust and thrust manipulations used were included.

Each patient had a slightly different treatment program based on the results of the clinical tests performed. Everyone was taught how to do lumbopelvic stabilization exercises. These exercises focused on abdominal and hip muscles (transverse abdominus, hip extensors, hip abductors).

Exercises to improve proprioception in a weight-bearing activity were also included. Taping was used with anyone who had pain when stepping down on stairs. Direction of taping used was based on which type of taping applied relieved the pain when stepping down. Patients were taught how to do their own taping at home.

Two of the patients received foot orthotics to correct ankle and foot alignment. This intervention approach is based on previous studies showing how a pronated (flat) foot position can chronically overload the patellofemoral joint.

The overall treatment plan was progressed for each patient from session to session based on individual results. Patient visits ranged from eight to 14 over a six to 11-week period of time. Treatment was discontinued when the patient no longer had pain or was able to return to sports activities.

All but one patient experienced significant improvements that were still present six months later. The results of this study support what other research has shown — a multimodal approach to PFPS can be very effective. Case series such as this one carefully tracking the management and outcomes of patients treated for PFPS can help direct future treatment for this problem.

The theory behind the multimodal approach is that using more than one technique to address the entire kinetic chain (foot to spine) works because it addresses the biomechanical links between the foot, ankle, knee, hip, pelvis, and spine. The results support the idea that PFPS occurs as a result of multiple interactions (dysfunctions) between these regions.

Treating the lower extremity as a functional unit may respond no matter what combination of specific interventions are used. The authors suggest that future studies are needed to confirm or correct this approach. And more studies are needed to compare thrust versus nonthrust techniques for each area (knee, hip, pelvis, spine).